[To be attached to Medical Report]

Date : 07/04/2023
To : The Medical Examiner
From : New Business & Underwriting Department

DOCTOR NOTIFICATION

Dear Doctor,

Proposal Number : 200727671

Name of Person Covered/Client NURUL 'AIN @ NURUL 'UYUN BT ABD RAHMAN
Name Of Participant : NURUL 'AIN @ NURUL 'UYUN BT ABD RAHMAN
Subject : Medical Requirement(s) for Family Takaful Application

We seek your assistance to conduct the following examination(s) for the above Client:-
NURUL 'AIN @ NURUL 'UYUN BT ABD RAHMAN

1. Urine FEME is required.

2 specimens on 2 different occasions (eg. one morning and one afternoon sample).

Prudential BSN Takaful Berhad (Company number: 200601020898)

Level 13, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur
Customer Service Hotline: 03 2053 7188 E-mail: customer@prubsn.com.my Website: www.prubsn.com.my

62701001 Page 1 of 2
MEDICAL CHIT

Proposal No: 200727671 Person Covered Name: NURUL 'AIN @ NURUL 'UYUN BT ABD RAHMAN
Date: ________________ Clinic Name: _________________________________________
Clinic Code: ________________ Doctor: _________________________________________

The following examination(s)/test(s) have been performed on the above client (Please tick the respective test(s)
done).

Examination/Test Charges(RM)
[ ] Medical Examination(ME) _________________
[ ] Medical Examination by Specialist(SME) _________________
[ ] Chest X-ray(CXR) _________________
[ ] Resting ECG(RECG) _________________
[ ] Stress ECG(SECG) _________________
[ ] Blood Draw _________________
[ ] Urine Collection _________________

Important Note:
1. IF there is Medical Examination requested, only clinical assessment is required(unless mentioned
above). If any additional test(s) are conducted, the additional assessment fee will be borne by the Client.
2. Please complete this Medical Chit and forward it to us together with the reports (except for test
results performed by our appointed laboratory) for reimbursement.
3. We encourage the doctor and Client to be of the same gender.

Doctor, please sign and affix clinic stamp at the end of this medical chit. Thank you.

Prudential BSN Takaful Berhad (Company number: 200601020898)

Level 13, Menara Prudential, Persiaran TRX Barat, 55188 Tun Razak Exchange, Kuala Lumpur
Customer Service Hotline: 03 2053 7188 E-mail: customer@prubsn.com.my Website: www.prubsn.com.my

62701001 Page 2 of 2